The reigning paradigm underlying the work of physicians is evidence-based medicine (EBM). EBM aims to apply the best available evidence gained from the scientific method to medical decision making. It assesses the quality of evidence regarding the risks and benefits of treatments.
Since the early 1990s, EBM has become widely disseminated among medical practitioners and is universally regarded as a major advance in medico-scientific thinking.1
One might expect, 10-20 years following such an advance, that the benefits of EBM would have shown up in the population. In some cases, the benefits are clear; for example the percent of patients with myocardial infarction taking beta-blockers has increased substantially.2
Yet for a number of conditions, a large proportion of patients remain in poor control despite excellent evidence guiding management and treatment. For two-thirds of Americans with diabetes and half of those with hypertension—conditions with strong evidence-based guidelines—these conditions are inadequately controlled.3,4
EBM has two major limitations: 1) the medical care system is not well structured to assist patients in incorporating the advances of EBM into their lives, and 2) the physical and social environment in which patients live create major challenges to patients’ ability to make the evidence-based changes required for disease control. We argue that EBM alone is insufficient as a guiding principle for medical practice and that a fundamental shift in thinking is needed. The following few paragraphs explain this paradigm shift.
The Chronic Care Model represents one effort to extend EBM by restructuring primary care, in particular by implementing planned visits—led by nurses, pharmacists health educators or health coaches—that provide patients with the knowledge, skills, and confidence to improve their health behaviors and increase medication adherence.5
These services are called “self-management support” (SMS), which has been shown to be the Model’s component most commonly associated with outcome improvements.6
This is not surprising since patients themselves make the day-to-day decisions regarding chronic conditions. Many SMS models exist, among them the Chronic Disease Self-Management Program in which trained patients lead a group of people with chronic conditions7
and the health coaching teamlet in which a trained health coach works closely with a clinician to provide self-management support in the primary care setting.8
Thus, SMS can be seen as the work needed to assist patients to incorporate EBM into their lives. One might then hypothesize that adding SMS to EBM leads to better population-wide outcomes. Yet the sum of these two inputs is still insufficient. Patients may try to incorporate EBM into their lives by making the recommended lifestyle changes, regularly monitoring their disease, and adhering to their medications, but often fail because the larger deck—their physical and social environment—is stacked against them. These community-based factors shape both the risk factors they are exposed to and their ability to effectively self-manage. For example, a woman living in a crime-infested neighborhood lacking healthy food outlets, facing barriers to healthy eating and regular exercise, would have great difficulty controlling her diabetes no matter how perfectly the health care team manages the disease and teaches her the knowledge and skills needed for diabetes control.
Efforts to address environmental factors—managing disease at the community level—represent an additional piece to the puzzle. We term such interventions “community health” (CH), meaning policies and actions that address problems in the physical and social environment. Community health entails two types of interventions:
- Individual level interventions that take place in the community. These seek to modify behaviors outside of the clinic doors. An example would be walking groups.
- Community level (structural) interventions that modify the environment in which individuals live. These acknowledge that individuals’ behaviors are constrained by larger forces. An example would be increasing the number of safe walking paths in a neighborhood.
An example that encompasses both categories would be organizing walking groups in an underserved urban area among patients attending a community clinic and assisting the walking group to advocate for new safe park in its neighborhood. CH has been siloed into the public health domain and has become philosophically and practically estranged from physicians and the medical care system. The focus of public health on the larger context of disease in society contrasts markedly with the medical system’s traditional focus on the individual patient.9
Physicians correctly argue that before concerning themselves with SMS and CH, they need evidence that these additions to EBM actually improve health. If, indeed, evidence exists supporting the addition of SMS and CH to EBM, then a new paradigm emerges, superseding EBM. In shorthand, EBH